Medical Insurance Associate - (U) - (4582)

The primary function is to perform duties and responsibilities for the Department of Medicine outpatient clinic. Specifically, this position is to assist patients in receiving the services and tests needed and to ensure that proper procedures are followed in compliance with the various insurance companies to ensure payment of those services. This position works under general supervision

*This position is ON SITE only*

Insurance Duties 80%

1. Independently initiates and completes managed care referrals/pre-authorizations as indicated by patients' needs and insurance requirements in order to secure approval for the patient's ongoing medical care. Enters referrals in the SMS system and links to appropriate appointments.
2. Reviews patient medical records for necessary documentation and disseminates the appropriate information to the managed care organizations in order to secure approval of the referrals.
3. Schedules patients' tests, procedures and referrals to specialty offices through phone calls and EHR to the proper hospital/specialist according to physician orders and the patient's insurance.
4. Prepares lab orders, assigns insurance codes and faxes orders and all necessary information to facility prior to scheduled test.
5. Calls patients to relay dates, times and special instructions for tests and referral appointments. Documents required information into the electronic health record.
6. Acts as liaison and advisor for patients, physicians, hospitals, insurance companies, government agencies and related interested parties regarding proper documentation, referral requests, authorization procedures and verification of factual information regarding patient's insurance and other sensitive issues within the field.
7. Secures additional health information from the patient and/or physician's office as needed, and initiates follow-up discussions with the managed care organizations in order to obtain a review of referrals for medical care. Assigns insurance codes to documentation to ensure proper level of payment.
8. Serves as a patient advocate in obtaining referrals to specialist physicians and health care agencies in a timely manner and directs patients to preferred hospital, laboratory, or agency where appropriate.
9. Reviews and analyzes processing procedures in order to identify potential problem areas and improve processing procedure.
10. Acts as an expert resource on managed care issues. Responds to a variety of questions from patients, nursing staff, physicians, hospitals, and insurance companies concerning the status of referrals and scheduled tests.

Administrative 20%

1. Attends training sessions and conferences to remain current regarding policies and procedures of managed care insurance; attends monthly SIU Managed Care Networking Group meetings to keep abreast of changes.
2. Maintains current information on all participating managed care plans in the clinic area including procedures, coding, etc.
3. Participates in the development of appropriate forms for internal and external use as they relate to referrals.
4. Participates on DGIM EHR team as it relates to the referral process.
5. Provides clinical staff and reception with updates on managed care plans.

Credentials to be Verified by Placement Officer

1. Any one or combination totaling one (1) year (12 months) from the categories below:
   1. College coursework in a health-related field, business administration/management, human resource management, or closely related fields as measured by the following conversion table or its proportional equivalent:
      • 30 semester hours equals one (1) year (12 months)
      • Associate's Degree (60 semester hours) equals eighteen months (18 months)
   2. Work experience in a healthcare environment working with medical claims, denials, rejections, referrals, and prior authorizations.

Knowledge, Skills and Abilities (KSA's)

1. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluating customer satisfaction.
2. Knowledge of the structure and content of the English language including the meaning and spelling of words, rules of composition, and grammar.
3. Knowledge of medical terminology and hospital or physician billing, coding, referrals, and prior authorizations.
4. Knowledge of basic arithmetic with the ability to add, subtract, multiply and divide whole numbers, decimals and percentages.
5. Skill in using computers and computer systems (including hardware and software) to program, write, set up functions, enter data, or process information.
6. Ability to pay close attention to details and follow established procedures in completing work tasks.
7. Ability to maintain patient confidentiality following HIPAA guidelines and established policies and procedures.
8. Ability to convey moderately complex billing, claims, referral, and prior authorization information to patients and staff.
9. Ability to train others to work collaboratively, building strategic relations with colleagues, coworkers, constituents.

Condition of Employment

Pursuant to the State Universities Civil Service System, an out-of-state resident who is hired into this position must establish Illinois residency within 180 calendar days of their start date.